Hypertension and the pregnancy complicated by diabetes

Diabetes is a frequent complication of pregnancy. Type 1 diabetes is associated with an increased incidence of preeclampsia and pregnancy-induced hypertension. When renal dysfunction is present, the incidence of these complications is remarkably increased. White's class, poor glycemic control during the first half of pregnancy, and early blood pressure elevation are also independent risk factors for developing preeclampsia. Whether gestational diabetes increases the background incidence of preeclampsia is still debated. Because therapeutic interventions such as low-dose aspirin and antioxidants have not been shown to be effective, preventive measures rely on tight blood glucose control, as well as adequate blood pressure treatment.     

No midpregnancy fall in diastolic blood pressure in women with a low educational level: the Generation R Study

Low socioeconomic status has been associated with preeclampsia. The underlying mechanism, however, is unknown. Preeclampsia is associated with relatively high blood pressure levels in early pregnancy and with an absent midpregnancy fall in blood pressure. At present, little is known about the associations among socioeconomic status, blood pressure level in early pregnancy, blood pressure change during pregnancy, and preeclampsia. We studied these associations in 3142 pregnant women participating in a population-based cohort study. Maternal educational level (high, midhigh, midlow, and low) was used as an indicator of socioeconomic status. Systolic and diastolic blood pressure was measured in early, mid-, and late pregnancy. Relative to women with high education, those with low and midlow education had higher mean systolic and diastolic blood pressure levels in early pregnancy; this was explained largely by a higher prepregnancy body mass index. Although women with high, midhigh, and midlow education had a significant midpregnancy fall in diastolic blood pressure, those with low education did not (change from early to midpregnancy: -0.38 mm Hg; 95% CI: -1.33 to 0.58). The latter could not be explained by prepregnancy body mass index, smoking, or alcohol consumption during pregnancy. The absence of a midpregnancy fall also tended to be related to the development of preeclampsia, especially among women with a low educational level (OR: 3.8; 95% CI: 0.80 to 18.19). The absence of a midpregnancy fall in diastolic blood pressure in women with a low education level may be a sign of endothelial dysfunction that is manifested during pregnancy. This might partly explain these women's susceptibility to preeclampsia.     

Endogenous soluble receptor for advanced glycation endproducts is increased in preeclampsia

OBJECTIVE: Preeclampsia is a serious complication in pregnancy with an increased future cardiovascular risk for both mother and newborn. Recently, low levels of endogenous soluble receptor for advanced glycation endproducts (esRAGE) have been associated with increased cardiovascular risk. In the current study, we investigated esRAGE serum levels in patients with preeclampsia as compared to healthy gestational age-matched controls. METHODS: esRAGE was quantified by enzyme-linked immunosorbent assay in controls and patients with preeclampsia during pregnancy (control: n = 20, preeclampsia: n = 16) and 6 months after delivery (control: n = 19, preeclampsia: n = 15). Furthermore, esRAGE was correlated to clinical and biochemical measures of renal function, glucose and lipid metabolism, as well as inflammation. RESULTS: During pregnancy, median maternal serum esRAGE concentrations were more than three-fold higher in patients with preeclampsia (200 ng/l) than in controls (63 ng/l) (P < 0.01). Furthermore, esRAGE levels positively correlated with age, blood pressure, creatinine, adiponectin, and C-reactive protein, whereas a negative correlation existed with fasting insulin and the homeostasis model assessment of insulin resistance index. In multivariate analyses, homeostasis model assessment of insulin resistance and C-reactive protein independently predicted esRAGE serum levels and explained 44% of the variation in esRAGE concentrations. Surprisingly, median esRAGE concentrations 6 months after delivery were significantly lower in former patients with preeclampsia (270 ng/l) than in controls (342 ng/l) in contrast to the results obtained during pregnancy. CONCLUSION: We showed that maternal esRAGE concentrations are significantly increased in patients with preeclampsia during pregnancy. Here, insulin sensitivity and inflammatory status independently predict serum esRAGE levels.     

Differences in circadian pattern of ambulatory pulse pressure between healthy and complicated pregnancies

With the use of ambulatory monitoring, a circadian blood pressure pattern has been shown to characterize normotensive as well as hypertensive pregnant women. However, the potential differences between healthy and complicated pregnancies in pulse pressure, an independent marker of cardiovascular risk in the general population, have not yet been investigated. We analyzed 2523 blood pressure series sampled for 48 hours once every 4 weeks from the first obstetric visit until delivery in 245 women with uncomplicated pregnancies, 140 with gestational hypertension, and 49 who developed preeclampsia. Compared with uncomplicated pregnancies, a statistically significant elevation in the 24-hour mean of pulse pressure is found in complicated pregnancies in all trimesters (P<0.001). Results further indicate similar 24-hour mean of pulse pressure between gestational hypertension and preeclampsia in the first trimester of pregnancy (P=0.158). The increase in pulse pressure among women who developed preeclampsia compared with women with gestational hypertension, although small, was statistically significant in the second trimester (1.4 mm Hg; P=0.010) and, to a larger extent, in the third trimester of pregnancy (1.8 mm Hg; P<0.001). The differences in pulse pressure between healthy and complicated pregnancies, observed already in the first trimester of gestation, are found when systolic and diastolic blood pressure for women with a later diagnosis of gestational hypertension or preeclampsia are within the accepted range of normotension. Moreover, ambulatory pulse pressure provides higher sensitivity than clinic measurements for the diagnosis of hypertension in pregnancy.     

Circulating angiogenic factors in the pathogenesis and prediction of preeclampsia

Preeclampsia is a major cause of maternal, fetal, and neonatal mortality worldwide. Although the etiology of preeclampsia is still unclear, recent studies suggest that its major phenotypes, high blood pressure and proteinuria, are due in part to excess circulating soluble fms-like tyrosine kinase-1 concentrations. Soluble fms-like tyrosine kinase-1 is an endogenous antiangiogenic protein that is made by the placenta and acts by neutralizing the proangiogenic proteins vascular endothelial growth factor and placental growth factor. High serum soluble fms-like tyrosine kinase-1 and low serum free placental growth factor and free vascular endothelial growth factor have been observed in preeclampsia. Abnormalities in these circulating angiogenic proteins are not only present during clinical preeclampsia but also antedate clinical symptoms by several weeks. Therefore, this raises the possibility of measuring circulating angiogenic proteins in the blood and the urine as a diagnostic and screening tool for preeclampsia. The availability of a test to predict preeclampsia would be a powerful tool in preventing preeclampsia-induced mortality, especially in developing nations, where high-risk specialists are limited. This review will summarize our current understanding of the role of circulating angiogenic proteins in the pathogenesis and clinical diagnosis/prediction of preeclampsia.     

Manifestations of metabolic syndrome after hypertensive pregnancy

Small follow-up studies of hospital-based series indicate women with preeclampsia have an increased risk of insulin resistance postpartum. However, long-term data are lacking among women with gestational hypertension without proteinuria. Using a general population-based sample of 5889 women from Northern Finland followed longitudinally since birth in 1966, we examined these associations and the influence of the subject's own birth weight and gestational age on this relationship. At age 31, blood pressure was measured and blood samples collected from 2678 women, of which 1463 women had had at least 1 singleton pregnancy. Of these, 45 had been hospitalized because of gestational hypertension and 49 because of preeclampsia. Women who had had either gestational hypertension or preeclampsia during their first pregnancy (average age 25 years) had increased blood pressure at 31 years compared with women with previous normotensive pregnancy, even after adjustment for body mass index (P<0.001 in gestational hypertension, P=0.023 in preeclampsia group). When compared with the whole female population, women with previous gestational hypertension at same age still had higher blood pressure, while this difference was weaker for women with previous preeclampsia. Women with gestational hypertension and preeclampsia also had higher waist circumference, waist/hip ratio, and body mass index, as well as increased serum insulin levels and lower glucose/insulin ratio than women with previous normotensive pregnancy. The associations remained after adjustment for participant's own birth weight or gestational age. Women born before gestational week 37 had a 2-fold risk for gestational hypertension in their first pregnancy (RR: 2.53; 95% CI: 1.0, 6.2).     

Lipid profile and cytokines in hypertension of pregnancy: A comparison of preeclampsia therapies

Hypertensive disorders complicating pregnancy can be classified as gestational hypertension, mild preeclampsia, and severe preeclampsia. It is necessary to evaluate and predict the grade in advance. The first study comprised 40 healthy pregnancies, 40 gestational hypertension, 40 mild preeclampsia, and 40 severe preeclampsia cases. The participants’ lipid profile and cytokine levels were statistically compared. The efficacy and safety of oral nifedipine (n = 71) and intravenous labetalol (n = 72) for the treatment of severe preeclampsia were evaluated in the next study according to maternal and neonatal outcomes. The levels of lipid profile and cytokines were linked with the presence and severity of hypertensive disorders complicating pregnancy. Both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe preeclampsia. Our study suggests that lipid profile and cytokines can be used in the evaluation of the severity of hypertensive disorders complicating pregnancy, and oral nifedipine requires more study.     

Glucocorticoid-remediable aldosteronism and pregnancy

Glucocorticoid-remediable aldosteronism (GRA) is a hereditary form of primary hyperaldosteronism that presents with hypokalemia and hypertension from childhood onward. GRA is characterized by the ectopic production of aldosterone in the cortisol-producing zona fasciculata under the regulation of adrenocorticotrophic hormone. Despite the early age of onset, no previous reports of pregnancy and GRA exist. Therefore, we set out to describe the maternal and fetal outcomes of pregnancy in women with GRA. Data regarding the blood pressure and pregnancy outcomes were collected in a retrospective chart review of prenatal and hospital records of 35 pregnancies in 16 women with genetically proven GRA. A total of 6% of pregnancies in women with GRA (GRA+) were complicated by preeclampsia. The published rates of preeclampsia in general obstetric populations vary from 2.5% to 10%. Despite the lack of an apparent increase in the rate of preeclampsia, GRA+ women with chronic hypertension had a high rate (39%) of pregnancy-aggravated hypertension. Starting with a higher baseline blood pressure, maternal blood pressure plotted over the time course of pregnancy followed a quadratic curve similar to that previously described in normal pregnancy. Mean gestational age at delivery was 39.1 weeks. Mean birth weight, excluding the 3 sets of twins, was 3219 g. However, infants of GRA+ mothers with pregnancy-aggravated hypertension tended to have lower birth weights than those that did not (3019 g versus 3385 g, respectively; P=0.08). The primary cesarean section rate was 32%, which is approximately double that seen in other general or hypertensive obstetric populations. In summary, GRA+ women did not seem to have an increased risk of preeclampsia. However, GRA+ women with chronic hypertension seem to be at an increased risk for an exacerbation of their hypertension during pregnancy.     

Hypertension in pregnancy

From the clinical point of view proteinuric hypertension or preeclampsia is the most important form of hypertension in pregnancy and carries the greatest risks for mother and foetus. The syndrome 'preeclampsia' differs from other types of hypertension and its effects on mother and foetus are not clearly benefited by lowering the blood pressure with drugs. The characteristic morphological changes and altered vascular reactivity which develop in preeclampsia commence at about 14 weeks gestation, long before hypertension or proteinuria appear. Many abnormalities in coagulation mechanisms appear in preeclampsia and some may play an important part in pathogenesis. Increased plasminogen activator inhibitor may play a key role. Antihypertensive drugs used during pregnancy may reduce foetal mortality and the incidence of preeclampsia. Calcium supplementation and aspirin may reduce the incidence of preeclampsia in high risk subjects. Heparin and dipyridamole may reduce the risk of preeclampsia in high risk patients with renal disease.     

Combined low-dose antihypertensive therapy in pregnant women with hypertension and preeclampsia

The effect of low-dose combination antihypertensive therapy in fixed form, containing 2.5 mg of bisoprolol and 6.25 mg of hydrochlorothiazide, the clinical condition, the daily profile of blood pressure, body adrenoreactivity structural and functional parameters of the left ventricle in 28 pregnant women with preeclampsia in the background chronic hypertension (hypertension stage II, 2 nd degree) and 28 pregnant women with preeclampsia and mild to moderate severity in terms of 22-28 weeks of pregnancy. After 16 weeks of receiving a fixed form, containing 2.5 mg of bisoprolol and 6.25 mg hydrochlorothiazide, the target BP level reached 76% of pregnant women with preeclampsia with chronic hypertension and 81% - with preeclampsia. In both groups, the parameters are optimized daily profile of blood pressure, the value of the total peripheral vascular resistance.     

Preeclampsia and hypertensive disease in pregnancy: their contributions to cardiovascular risk

More women than men die each year of cardiovascular disease, which remains the leading cause of death in the United States. Sex-specific factors, including pregnancy-related disorders, should be considered when assessing cardiovascular (CV) risk in women. Hypertensive disorders of pregnancy have been associated with CV risk later in life and may identify women in whom earlier primary prevention may reduce their risk. This article reviews the physiologic changes in blood pressure during pregnancy, current definitions of hypertensive diseases of pregnancy and preeclampsia, and postulated pathophysiologic mechanisms leading to preeclampsia that might contribute to later CV risk. Also summarized are studies providing evidence on the association between hypertensive diseases of pregnancy and future CV risk.     

High normal blood pressure in early pregnancy also contribute to early onset preeclampsia and severe preeclampsia

Objective: This study was to evaluate effects of high normal blood pressure (HNBP) in early pregnancy on total preeclampsia, early preeclampsia, and severe preeclampsia.

Methods: We conducted a multicenter, national representative retrospective cohort study. HNBP was defined as systolic blood pressure between 130 and 140 mmHg or diastolic blood pressure between 85 and 90 mmHg. We used multivariable logistic regression to examine the associations of HNBP and the risks of above three types of preeclampsia.

Results: We included 58 054 women who were normotensive and nulliparous in early pregnancy. 4 809 (8.3%) fulfilled the definition of having HNBP, 16 682 (28.7%) were in normal blood pressure group, and 36 563 (63.0%) were in optimal blood pressure group. The incidence rates of total preeclampsia, early preeclampsia, and severe preeclampsia were 2.1% (1 217), 0.8% (491), and 1.4% (814), respectively. Compared to having optimal blood pressure, women with HNBP had significantly higher odds of total preeclampsia (odds ratio (OR) = 4.028, 95% confidence interval (CI) 3.377, 4.804), severe preeclampsia (OR = 3.542, 95% CI 2.851, 4.400), and early preeclampsia (OR = 8.163, 95% CI 6.219, 10.715). Our restricted cubic spline results supported the dose–response relationship between continuous blood pressure and the odds ratio of three types of preeclampsia. The fraction of early preeclampsia associated with prehypertension was 58.6%, which was higher than those of total preeclampsia (42.2%) or severe preeclampsia (40.5%).

Conclusion: Women in early pregnancy with HNBP more likely develop total preeclampsia, early preeclampsia and severe preeclampsia, compared to those with optimal blood pressure. HNBP contribute more to early preeclampsia than severe preeclampsia. Our study provided robust epidemiological evidences for monitoring HNBP in early pregnancy to reduce the risks of preeclampsia.     

Preeclampsia

The case of a 32-year-old primigravida, 32 weeks gestation, with nausea, vomiting, thrombocytopenia, and abnormal liver function tests is presented. A diagnosis of severe preeclampsia was made and the patient underwent emergency cesarean section. Improvement of clinical symptoms and laboratory studies followed over the succeeding days. These less common manifestations of preeclampsia indicate severe disease necessitating aggressive management, even in the setting of a normal blood pressure. Thrombocytopenia, microangiopathic hemolytic anemia, or abnormal liver functions in a patient presenting in the latter half of pregnancy may be manifestations of severe preeclampsia.     

Blood pressure patterns in normal pregnancy, gestational hypertension, and preeclampsia

With the aim to describe the daily pattern of blood pressure during the trimesters of pregnancy in clinically healthy women as well as in pregnant women who developed gestational hypertension or preeclampsia, we analyzed 1494 blood pressure series systematically sampled by ambulatory monitoring for 48 hours every 4 weeks after the first obstetric visit in 124 women with uncomplicated pregnancies, 55 with gestational hypertension, and 23 with a final diagnosis of preeclampsia. The circadian pattern of blood pressure variation for each group and trimester of gestation was established by population multiple-component analysis. A highly statistically significant circadian pattern represented by a linear model that includes components with periods of 24 and 12 hours is demonstrated for systolic and diastolic blood pressure for all groups of pregnant women in all trimesters (P:<0.001 in all cases). The differences in circadian rhythm-adjusted mean between complicated and uncomplicated pregnancies are highly statistically significant in all trimesters (always P:<0.001). There is also a statistically significant difference in circadian amplitude (extent of daily change) of blood pressure between healthy and complicated pregnancies in all trimesters (always P:<0.004). Results further indicate similar circadian characteristics between women who later developed gestational hypertension or preeclampsia in the first trimester of pregnancy. The difference between these 2 groups in circadian mean is statistically significant in the second trimester for systolic (P:=0.022) but not for diastolic blood pressure (P:=0.986). In the third trimester, the difference in circadian mean is highly statistically significant for both variables (P:<0.001). The differences in blood pressure between healthy and complicated pregnancies can be observed as early as in the first trimester of pregnancy. Those highly significant differences are found when both systolic and diastolic blood pressure for women with a later diagnosis of gestational hypertension or preeclampsia are well within the accepted normal physiological range of blood pressure variability. These differing changes in the circadian pattern of blood pressure with advancing gestational age between healthy and complicated pregnancies offer new end points that may lead to an early identification of hypertensive complications in pregnancy as well as to the establishment of prophylactic intervention.     

New insights into the importance of aminopeptidase A in hypertension

The renin-angiotensin system (RAS) plays an important role in the maintenance of normal blood pressure and the etiology of hypertension; however, minimal attention has been paid to the degradation of the effector peptide, angiotensin II (AngII). Since aminopeptidase A (APA)-deficient mice develop hypertension APA appears to be an essential enzyme in the control of blood pressure via degradation of AngII. The robust hypertension seen in the spontaneously hypertensive rat (SHR) is due to activation of the RAS, and an accompanying decrease in kidney APA. Changes in APA have also been measured during the activation of the RAS in the Goldblatt hypertension model and Dahl salt-sensitive (DSS) rat. The DSS rat shows an elevation in renal APA activity at the onset of hypertension suggesting a protective role against elevations in circulating AngII, followed by decreased APA activity with advancing hypertension. Changes seen in human maternal serum APA activity during preeclampsia are similar to changes measured in renal APA in the DSS rat model. APA activity is higher than during normal pregnancy at the onset of preeclampsia, and with advancing preeclampsia (severe preeclampsia) declines below that seen during normal pregnancy. Serum APA activity is also increased during hormone replacement therapy (HRT), perhaps in reaction to elevated levels of AngII. Thus, it appears important to consider the relationship among activation of the RAS, circulating levels of AngII, and the availability of APA in hypertensive disorders.     

Low placental growth factor across pregnancy identifies a subset of women with preterm preeclampsia: type 1 versus type 2 preeclampsia?

Preeclampsia is a heterogeneous syndrome affecting 3% to 5% of all pregnancies. An imbalance of the antiangiogenic and proangiogenic factors, soluble receptor fms-like tyrosine kinase 1 and placental growth factor (PGF), is thought to contribute to the pathophysiology of preeclampsia. Maternal plasma PGF and soluble receptor fms-like tyrosine kinase 1 were quantified by specific immunoassays in cross-sectional samples from 130 preeclamptic subjects and 342 normotensive controls at delivery and longitudinally in samples from 50 women who developed preeclampsia and 250 normotensive controls. Among women who developed preeclampsia, 46% (n=23) evidenced a pattern of consistently low maternal PGF across pregnancy below the lower 95% CI of controls from 15 weeks' gestation to term. In contrast, the remaining 54% (n=27) of women who developed preeclampsia had maternal PGF concentrations similar to or above (n=7) those of normotensive controls. Subjects with low PGF across pregnancy who developed preeclampsia evidenced significantly higher blood pressure in early pregnancy (P<0.05) and, after diagnosis, earlier gestational age at delivery (P<0.05) and more preterm birth (P<0.05) compared with preeclamptic patients with high PGF. A significant subset of women who develop preeclampsia show evidence of consistently low PGF across pregnancy. Low PGF with preeclampsia was associated with preterm delivery compared with preeclamptic patients with high PGF. Identifying women with consistently low plasma PGF during pregnancy may provide a greater understanding of preeclampsia pathophysiology and may provide more focused research and clinical activities.     

Preeclampsia is associated with persistent postpartum cardiovascular impairment

Preeclampsia is associated with asymptomatic global left ventricular abnormal function and geometry during the acute phase of the disorder. These subclinical abnormalities in cardiac findings are known to be important in cardiovascular risk stratification for nonpregnant patients. Furthermore, epidemiological studies have also demonstrated a relationship between preeclampsia and cardiac morbidity and mortality later in life. The aim of this study was to evaluate the postpartum natural history and clinical significance of asymptomatic left ventricular impairment known to occur with acute preeclampsia. This was a prospective longitudinal case-control study of 64 subjects with preeclampsia and 78 matched controls. There were 3 time point assessments, pregnancy and 1 and 2 years postpartum. The assessments included a medical and family history, blood pressure profile, echocardiography, and 12-lead ECG. At 1 year postpartum, asymptomatic left ventricular moderate-severe dysfunction/hypertrophy was significantly higher in preterm preeclampsia (56%) compared with term preeclampsia (14%) or matched controls (8%; P values <0.001). The risk of developing essential hypertension within 2 years was significantly higher in both preterm preeclamptic women and those with persistent left ventricular moderate-severe abnormal function/geometry. The cardiovascular implications of preeclampsia do not end with the birth of the infant and placenta. The majority of preterm preeclamptic women have stage B asymptomatic heart failure postpartum, and 40% develop essential hypertension within 1 to 2 years after pregnancy. Women with a history of preterm preeclampsia may benefit from formal cardiovascular risk assessment in the 1 to 2 years after delivery to identify those who would benefit from targeted therapeutic intervention.     

Hypertension in CKD Pregnancy: a Question of Cause and Effect (Cause or Effect? This Is the Question)

Chronic kidney disease (CKD) is increasingly encountered in pregnancy, and hypertension is frequently concomitant. In pregnancy, the prevalence of CKD is estimated to be about 3 %, while the prevalence of chronic hypertension is about 5–8 %. The prevalence of hypertension and CKD in pregnancy is unknown. Both are independently related to adverse pregnancy outcomes, and the clinical picture merges with pregnancy-induced hypertension and preeclampsia. Precise risk quantification is not available, but risks linked to CKD stage, hypertension, and proteinuria are probably multiplicative, each at least doubling the rates of preterm and early preterm delivery, small for gestational age babies, and related outcomes. Differential diagnosis (based upon utero-placental flows, fetal growth, and supported by serum biomarkers) is important for clinical management. In the absence of guidelines for hypertension in CKD pregnancies, the ideal blood pressure goal has not been established; we support a tailored approach, depending on compliance, baseline control, and CKD stages, with strict blood pressure monitoring. The choice of antihypertensive drugs and the use of diuretics and of erythropoiesis-stimulating agents (ESAs) are still open questions which only future studies may clarify.     

Hypertensive complications of pregnancy: A clinical overview

Hypertensive disorders in pregnancy are a worldwide health problem for women and their infants complicating up to 10% of pregnancies and associated with increased maternal and neonatal morbidity and mortality. In Europe, 2.3–3% of pregnancies are complicated by preeclampsia. Gestational diabetes, obesity, no previous or multiple births, maternal age less than 20 or greater than 35 years old and thrombophilia can be some of the possible factors related to increased risk for hypertension in pregnancy. Complications of hypertension during pregnancy affect both mothers and their infants. Ambulatory blood pressure monitoring helps to distinguish true hypertension from the white coat as pregnant women with office abnormal values may have normal out of office blood pressure. Imbalance between proangiogenic and antiangiogenic factors in placenta may lead to endothelial dysfunction, vasoconstriction, activation of the coagulation system, and hemolysis. Carotid intima-media thickness, pulse wave velocity, augmentation index, and arterial wall tension were found to be significantly increased in women with preeclampsia compared to normotensive pregnant women. Uterine artery Doppler and serum biomarkers can be used to evaluate the probability of hypertension and complications during pregnancy, but further research in the field is needed. Lately, micro ribonucleic acids have also been the focus of research as potential biomarkers.     

Hypertension in pregnancy

Hypertension complicates 5% to 7% of all pregnancies. A subset of preeclampsia, characterized by new-onset hypertension, proteinuria, and multisystem involvement, is responsible for substantial maternal and fetal morbidity and is a marker for future cardiac and metabolic disease. This American Society of Hypertension (ASH) position paper summarizes the clinical spectrum of hypertension in pregnancy, focusing on preeclampsia. Recent research breakthroughs relating to etiology are briefly reviewed. Topics include classification of the different forms of hypertension during pregnancy, and status of the tests available to predict preeclampsia, and strategies to prevent preeclampsia and to manage this serious disease. The use of antihypertensive drugs in pregnancy, and the prevention and treatment of the convulsive phase of preeclampsia, eclampsia, with intravenous MgSO₄ is also highlighted. Of special note, this guideline article, specifically requested, reviewed, and accepted by ASH, includes solicited review advice from the American College of Obstetricians and Gynecologists.